• Nama : Dr. Reno Rudiman, dr.

, MSc,
SpB-KBD, FCSI, FICS
• No. Telp : +62 811222074
• E-mail : rudiman@unpad.ac.id

• 1983-1989 FK UNPAD Bandung

• 1992-1993 Master of Science in Research
Methodology, University of Aberdeen, UK
• 1994-1998 PPDS FK UNPAD Bandung
• 1998-2000 Konsultan Bedah Digestive FK UNPAD
• 2007-2012 Program Doktor FK UNPAD

• Kepala Program Studi Ilmu Bedah FKUP/RSHS

Bandung
Reno Rudiman, MD, MSc, PhD, FCSI, FICS
Consultant in Digestive Surgery

ROLE OF ERCP IN
ACUTE CHOLANGITIS

Hasan Sadikin General Hospital, Bandung, Indonesia

Endoscopic Retrograde
Cholangio-Pancreatography

For biliary stone removal

• Endosopic retrograde
cholangiopancreatography (ERCP) was
introduced over 40 years ago.
• Since then, choledocholithiasis and
hepatolithiasis have been removed with
this method
ERCP for Biliary Stones
History

The name ERCP was approved by this working group at the Mexico City World
Congress in 1974: Zazuei Ogoshi, Laszlo Safrany, Meinhard Classen, Tatsuzo Kasugai,
Peter Cotton and Jack Venne
Room set up
Positions

• Prone
• Semi prone
• Supine
Endoscopic Retrograde
Cholangio-Pancreatography

In Acute Cholangitis

• ERCP is the gold standard for diagnosing

Acute Cholangitis
• Can be as evaluating method for other
modalities such as MRCP
• High success rate (98%)
• Complete assessment of biliary tree, up to
the smallest branches
Endoscopic Retrograde
Cholangio-Pancreatography

In Acute Cholangitis
• ERCP can serve as a therapeutic procedure
for biliary drainage
• A therapeutic alternative for patients who
may not tolerate surgical drainage
interventions
• ERCP-guided implantation of a biliary
endoprosthesis or stent represents the gold
standard therapeutic for biliary stricture
Endoscopic Sphincterotomy
Indication

• Extraction of common bile duct stones

• Treatment of papillary stenosis
• Facilitation of endotherapy
▪ Placement of stents
▪ Tissue sampling
▪ Stricture dilatation
Endoscopic Sphincterotomy
Contra Indication

• Recent myocardial infarction

• Severe cardiopulmonary disease
• Recent attack of acute pancreatitis
• Allergic reaction to contrast dye
Endoscopic Sphincterotomy
Papillotome

• Push
• Pull
• Needle knife

Erlangen pull papillotome

Endoscopic Sphincterotomy
Guidewire
• Teflon coated guide wire,
• Teflon sheathed wire (glide wire),
• and other Teflon sheathed wires (including the
Zebra, Visi-Glide Jaguar, Hydra-Jag wires, and
Metro wires).
• Teflon-sheathed wires are preferred to Teflon-
coated wires because they may be less likely to
short-circuit.
Endoscopic Sphincterotomy
Guidewire
Cannulating the papilla
Sphincterotomy
Endoscopic Papilla
Large Bile Dilation
EPLBD

• Enables larger stones to be removed effectively

• Up to 10mm dilation is possible

• Risks of pancreatitis and perforation are higher

• Its complications prohibits its use routinely

Endoscopic Papilla
Large Bile Dilation
EPLBD
Complications of ERCP
Most common

• Pancreatitis

• Cholangitis

• Hemorrhage

• Perforation
Pancreatitis Risk Factors

Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis:

a comprehensive review. Gastrointest Endosc 2004;59:845-64
Pancreatitis Prevention

• Selective cannulation, avoid pancreatic duct injection

if pancreatogram is not required

• Use only few mililiters of contrast for pancreatogram

• A 50-mL syringe delivers less pressure

• During ES, use more cutting than coagulation - less

edema and tissue injury
Pancreatitis Treatment

• Most cases will resolve with moderate treatment

• Restriction of oral intake, and iv fluid until the

symptoms resolve, and serum amylase & lipase
normalize

• Necrotic pancreatitis needs debridement &

necrosectomy
Post ERCP Cholangitis

• Post ERCP Cholangitis is extremely rare (0.1%)

• Occurs only in jaundiced patient with obstructed

biliary systems.

• Risk for cholangitis in stenting in malignant biliary

strictures, and in failed biliary drainage

• Prevention by timely relieve of obstruction

Cholangitis Treatment

• Immediate drainage is indicated

• Antibiotic is needed

• Mortality is high when the patient

progressed to septic shock
Hemorrhage

• Clinically significant bleeding after ES is 2%

• Minor bleeding (oozing) is frequent, will stop spontaneously if

coagulation parameters are normal

• Important to check PT before procedure

• If ES can be delayed, correct PT with vit K subcutaneously

• If ES is urgent, give FFP

• Patient with anti platelet medication, discontinue drug for 7-10 days
Hemorrhage Prevention

• ES as close to the 12 o'clock position to avoid duodenal

vasculature

• A blended cutting current should be used

• ES should be made slowly in sequenced steps

• Tailor the size as needed (small ES for small stones)

• Do not forcefully extract large stones; use mechanical lithotriptor

Hemorrhage Treatment

• Minor oozing usually stops spontaneously

• Minor bleeding can be treated by epinephrin injection

to the bleeding point using variceal injection device

• Brisk arterial bleeding must be treated aggressively;

embolization or operative intervention (Duodenotomy)
Perforation

• Perforation following ES is
rare; 0.3% of cases

• Symptoms: abdominal and

back pain, fever,
leucocytosis

• X-ray: retroperitoneal air

ERCP Perforation

• Type 1: Lateral duodenal wall

• Type 2: Peri-Vaterian

• Type 3: Duodenal injury

• Type 4: Retroperitoneal air

Howard T et al. Surgery 1999

Stapher M et al. Ann Surgery 2000
Enns R et al Endoscopy 2002
Characteristics of Perforation

Howard T et al. Surgery 1999

Stapher M et al. Ann Surgery 2000
Enns R et al Endoscopy 2002
Perforation Prevention

• Use sphincterotome with short cutting wire (20-25mm)

• Do not extend the ES beyond duodenal transverse fold

• Tailor the ES length as needed

Perforation Treatment

• If recognized early, manage conservatively:

NGT & antibiotics

• If failed to improve in 24-48 hours;

operative treatment

• Primary closure, omental patch. Pyloric exclusion

may be needed. Gastrojejunostomy and T-tube drain
Conclusion

• ERCP is an effective tool for biliary

drainage in acute cholangitis

• Risks of pancreatitis and perforation